GoatThroat Order Form

GoatThroat Order Form

GoatThroat pumps and accessories for delivery to the USA, Canada and Mexico may be ordered by completing the form below, or by contacting any of our Authorized Distributors. If outside North America, please contact us for information about distributors in your area. To order, please print this page using the "Print this Page" button below and fax to our secure fax line at 212-243-6070.

Model	Description	Unit Price	Qty	Total
ST-04	Set of 4 9" Siphon Tubes (1 lb)	$25.00		$25.00


	Shipping Cost:
	Total:		1

NOTE: New York State purchasers must include 8.375% sales tax (not included in estimated total above). For credit card orders, please allow 7-10 business days for delivery. Please make checks payable to Westcott Distribution, Inc. Orders paid by check will be shipped when check clears. Please contact us for further information or special delivery requests.

Specific Fluid/Chemical Information:
Fluid Used:
Shipping Address:
Name:
Company:
Address:


City:		State:
Zip / Postal Code:		Country:
Telephone:		Fax:
E-Mail:
Shipping Information:		Account #
How did you hear about us? (or coupon code)	Any discount, if applicable, will be taken off when order is processed.

Click this checkbox if Billing Address differs from Shipping Address

Billing Address:
Name:
Company:
Address:


City:		State:
Zip / Postal Code:		Country:
Telephone:		Fax:

Payment Method:
Type:
Credit Card Number:
Expiration Date:
Card Security Code:

Finalize Order:
To order, please print this page and fax to our secure fax line at 212-243-6070. Or send by mail to address at right:			Westcott Distribution, Inc. 60 Shell Avenue Milford, CT 06460 Tel: 646-486-3636 Email: info@GoatThroat.com

Note:
To safeguard your privacy, please do not send this form by e-mail, which is not secure and incurs a small but potential risk of interception.